Gold Simple PPO 0/0/25 + Gold + PPO – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $8,550 per person $17,100 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $200 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | $4,000 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $2,000 copay |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $4,000 copay |
Pharmacy, Drugs, and Medication
| Generic | $4 per script copay |
| Brand | $45 per script copay |
| Non-preferred Brand | $70 per script copay |
| Specialty | 20%, up to $250 per script copay, 20%, up to $250 per script coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay |
| Imaging (CT/PET/MRI) | $200 copay |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | $4,000 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/MocTSzQ8wrMzoeUTjRxdXbig.pdf |
| Drug and medication plan formulary | https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage |
